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Chapter 20

Family Planning and Infertility

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Chapter 20
Lesson 20.1

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Objectives
1. 2.

3. 4.

5.

6.

Define key terms listed. Identify factors that influence the woman’s choice of contraceptive method. Discuss five types of contraception. Explain how the male condom should be used to be most effective. Describe a method of contraception that reduces the risk of sexually transmitted infections. List advantages and disadvantages of five types of contraception.

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Family Planning

Choice involves
    

Personal Social Economic Religious Cultural

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Reversible Contraception

Decisions on what to use should be
 

Voluntary With full knowledge of • Advantages and disadvantages • Effectiveness • Side effects • Contraindications • Long-term effects

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Factors in Selecting Contraception
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Cost of method Effectiveness Availability Partner’s support and willingness to cooperate Safety of method Protection against sexually transmitted infections (STIs) Convenience Desirability or personal preference Personal motivation and compliance Religious and moral factors Medical problems

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Abstinence


Acts as a contraceptive by eliminating the possibility of sperm entering the woman’s vagina. Completely effective in preventing pregnancy Is a means of avoiding STIs Rhythm method of contraception includes abstinence during her menstrual cycle when she is most fertile

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Fertility Awareness

The understanding that a woman is fertile at ovulation Time of ovulation can be confirmed by
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Basal body temperature (BBT) Cervical mucus method (aka Billings method) Symptothermal method Chemical predictor test Rhythm methods (aka calendar method)

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Mechanical Barrier Methods
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Chemicals or devices Prevent transport of sperm to cervix or implantation of fertilized ovum Spermicides inserted at least 1 hour before coitus

Rarely effective if used alone; use with condom, diaphragm, or cervical cap

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Vaginal Spermicides
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Immobilize and destroy sperm Neutralize vaginal secretions Viruses and some other pathogens are not susceptible to spermicides Cannot be relied on to protect against STIs Examples: creams, foams, film, suppositories

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Spermicides

Activate when exposed to body warmth in vagina

Short acting  Inactive within an hour after insertion  A single application provides protection against 1 ejaculation  Can be messy, leak
 

Low cost and safe Failure rate is 6%

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Male Condom
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Flexible sheath worn over erect penis Inexpensive, accessible, effective means of contraception Reduces spread of STIs Failure rate 3%; if used with spermicides, failure rate 2% or less 4 basic features differ among condoms
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Material: latex or polyurethane Shape: reservoir at tip Lubricant: wet jelly or dry powder Spermicides

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Male Condom (cont’d)

Latex

Prolonged storage in hot humid climates, or contact with vaginal antifungal creams, suntan oil, or oil-based lubricants, such as petroleum jelly, will cause the latex to break down and the condom will be ineffective for birth control

Polyurethane

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Less constricting fit, more resistant to deterioration May enhance sensitivity Compatible with oil-based lubricants Protect against STIs

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Female Condom

A thick lubricated polyurethane sheath, 7 inches long with flexible ring at each end
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Inner ring serves as means of insertion Covers cervix like diaphragm 2nd rings remains outside vagina

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Can insert up to 8 hours before intercourse OTC and single use only Do not use with male condom Failure rate is 21%

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Diaphragm

Latex or rubber cup surrounded by spring or coil that fits snugly over cervix

Can put spermicidal cream or gel in dome and around rim

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Prevents passage of sperm into cervix Requires fitting by health care provider

Size should be rechecked after each term birth or if woman gains or loses 4.5 kg (10 lb)

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Diaphragm (cont’d)

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Holds spermicide in place against cervix for the 6 hours it takes to destroy the sperm Can be inserted up to 4 hours before intercourse Spermicide must be inserted into vagina each time intercourse is repeated Do not leave in place longer than 24 hours Cannot be relied on to protect against STIs Failure rate is 6%

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Cervical Cap

Cup-shaped device, smaller than diaphragm
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Once placed over cervix, remains in placed by suction Not all women can be fitted for this


Can remain in place 24 to 48 hours Fitting should be checked yearly, after childbirth, and after vaginal or uterine surgery

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Intrauterine Device (IUD)

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Small, T-shaped, flexible device inserted by health care provider Provides continuous pregnancy prevention Most often prescribed for women who have had at least 1 term pregnancy Not recommended for women with multiple sexual partners Does not protect against STIs

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Contraindications for IUD Insertion
     


Liver disease Copper allergy Breast cancer Immunodeficiency disorders Immunosuppressive therapy Uterine abnormalities Pelvic infection or disorder Undiagnosed vaginal bleeding

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Hormonal Contraceptives

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Oral Contraceptives (OCs)

Birth control pill

Prevents pregnancy by suppressing ovulation through combined actions of synthetic estrogen and progestin  Thickens cervical mucus  Alters decidua of uterus, preventing implantation

Failure rate 1% if taken as directed

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“Minipill”
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Contains only progestin Works in same way as regular pill but is less effective in suppressing ovulation

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Side Effects of OCs

Can range from nausea to breakthrough bleeding to thrombus formation

May be either estrogen or progestin related

Adolescents must have at least 3 ovulatory cycles before starting OCs After term delivery, OCs can be started about 4 weeks postpartum OCs can decrease volume of breast milk, so do not start until milk well established

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Warning Signs for OC Use

Woman should be instructed to notify health care provider if she has

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Breast lump Depression Jaundice Abdominal pain Severe leg pain Severe headaches or dizziness Weakness or numbness Vision loss or blurred vision Speech problems Chest pain, cough, or shortness of breath

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Contraindications to OCs

Vascular pathologic conditions
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Thromboembolism or pulmonary embolism Stroke, atherosclerosis, heart disease or failure Hypertension


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Breast cancer within 5 years Diabetes with neuropathy Retinopathy, liver disease Smoking Age older than 35 years Pregnancy Migraines with aura

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Education About OCs
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Proper use can increase effectiveness Combination OCs come in packets of 21 or 28 tablets Important to take pill at same time every day

Keeps blood hormone levels stable


Review what she should do if a pill is missed Certain drugs, such as antibiotics, can interfere with effectiveness of OC

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Follow-up Care for Women Taking OCs
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Yearly pelvic examination Pap smear Breast examination Blood pressure measurement

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Hormonal Skin Patch

Applied to dry skin of buttock, abdomen, upper arm, or torso on 1st day of menstrual period

Wear patch for 1 week and replace each week x 3; week 4 is patch free

Advantages: consistent level of hormone in blood, avoids liver metabolism Not recommended for women weighing 90 kg (198 lb) or more

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Vaginal Ring

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Flexible silicone ring inserted into vagina for 3 weeks, removed for 1 week to allow for menstruation Provides steady low-dose hormone Leukorrhea and vaginal infections common side effects Fertility returns rapidly after ring discontinued

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Implantable Contraceptives

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Implanon, single silicone rod that uses etonogestrel Inserted subdermally Provides contraception for 3 years Does not prevent STIs Can be inserted or removed in outpatient clinic under local anesthesia

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Injectable Contraceptives

Depo-medroxyprogesterone acetate (DMPA) suspension (Depo-Provera)
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Long-acting, injectable progestin Alters cervical mucus so it is hostile to sperm • Impairs ovulation and implantation Contraceptive effect could last up to 1 year

Single injection every 3 months

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Pregnancy test performed before 1st injection Side effects: menstrual spotting, headache, weight gain; does not protect against STIs

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Emergency Contraception

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Effective if started 24 to 72 hours after unprotected intercourse Take 1 pill, then another 12 hours later Side effects include nausea, vomiting, breast tenderness, and menstrual irregularities Noncompliance with regimen is most common cause of failure

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Least Effective Methods of Contraception

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Coitus Interruptus (Withdrawal)


Man withdraws penis from vagina before ejaculation Prevents large quantity of sperm from being deposited into vagina May misjudge timing and withdraw too late Also, fluid that escapes from penis before ejaculation also contains sperm
NOT A RELIABLE METHOD OF BIRTH CONTROL

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Postcoital Douche

Sperm are known to appear in cervical mucus within a few seconds after ejaculation Sperm can reach site of fallopian tube within a short time Once sperm are in tube, pregnancy can results and douching will not prevent this
NOT A RELIABLE METHOD OF BIRTH CONTROL

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Breastfeeding

Inhibits ovulation because prolactin alters ovarian response to hormones and return of menses Frequency, intensity, and duration of breastfeeding may maintain anovulatory status for 4 to 6 months; then prolactin decreases and ovulation returns Pregnancy can occur before menses returns
NOT A RELIABLE METHOD OF BIRTH CONTROL

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Permanent Contraception

Legal aspects

Informed consent • Should include risks, benefits, alternatives, and a
statement that procedure is permanent and may be irreversible

 

No absolute guarantee that the procedure will prevent pregnancy in most procedures Some states require a 30-day waiting period

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Male Sterilization

Minor surgical procedure

3-cm incision made and vas deferens is severed and occluded

Takes approximately 6 weeks and up to 36 ejaculations to clear remaining sperm On follow-up visits, man may be asked to submit semen samples to assess sperm count Can be reversed in some cases Vasectomy has no effect on sexual performance

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Female Sterilization
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 

Tubal ligation: surgical procedure Transcervical occlusion: a coil is inserted into each fallopian tube, leading to complete occlusion within 3 months Neither protects against STIs Does not affect menstruation or sexual performance

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Nursing Responsibilities Related to Sterilization
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Listen to patient’s concerns Verify information regarding benefits, risks, and alternatives Provide emotional support Discuss
 

Preoperative and postoperative care Signs and symptoms to report

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Chapter 20
Lesson 20.2

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Objectives
7. 8. 9.

10.
11. 12.

Describe a therapy to facilitate pregnancy. Review factors that contribute to infertility. Describe four types of treatment protocols in the management of infertility. Explain male sterilization. Explain female sterilization. Discuss the role of the nurse in caring for patients with contraceptive or fertility problems.

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Infertility and Therapies to Facilitate Pregnancy

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Definitions of Fertility and Infertility

Fertility: the capacity to conceive or reproduce Infertility: the inability to conceive or reproduce after 1 year of regular, unprotected sexual intercourse; or the inability to conceive at the time desired Sterility: partner has irreversible factor that prevents fertility

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Infertility
   

Primary Secondary Unsuccessful pregnancy Single infertility

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Cultural and Religious Considerations

Fertility (or lack of) is strictly seen as a female problem by some cultures Stigma of infertility can lead to divorce or rejection by family or society Religious norms influence what tests or treatments can be pursued

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Factors in Fertility
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Coital frequency: 3 times per week Age: woman older than 35 years Smoking: increases peristalsis of fallopian tubes Exercise and weight loss

Too much exercise—menstrual irregularity  Excessive weight—amenorrhea
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Diet: B12 deficiency Stress: significant cause of infertility Medical conditions

Pelvic adhesions, pelvic inflammatory disease  Endocrine disorders

Use of drugs (prescription or illicit) Exposure to chemicals

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Infertility Management Program
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Contributing factors are discussed Before treatment is initiated, diagnostic tests may be performed Tests may include tubal function, ovulation, hormone levels, BBT, endometrial biopsy Multidisciplinary team includes endocrinologist, urologist, psychologist, gynecologist, nurse, and the couple

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CAM Medical Therapy for Infertility

Acupuncture thought to increase sperm counts in the male

Ginseng and astragalus

Enhance assisted reproductive technology in the female

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Male Infertility
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Defect in transport system of sperm Defect in sperm production Inability to deposit sperm into woman Use of tobacco, alcohol, illicit drugs can also contribute Some prescription drugs can inhibit sperm production, cause ejaculatory problems, or lead to erectile dysfunction

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Fertility Tests for Males
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Semen and sperm analysis Transrectal ultrasound Hormonal profile Postejaculatory urinalysis to test for retrograde ejaculation Vasograph Genetic testing Postcoital sperm count

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Treatment of Male Infertility
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Surgical intervention for varicocele Antimicrobial therapy for genital infections or trauma to reproductive tract Medications and mechanical aids can be used for erectile dysfunction Instruct male to wear loose-fitting underwear; avoid saunas, smoking, St John’s wort, anabolic steroids; and eat healthy diet

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Treatment of Female Infertility

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Transcervical balloon tuboplasty to unblock fallopian tubes Laparoscopy or laparotomy Laser to remove scar tissue

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Assisted Reproductive Technology

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Legal and Ethical Factors in Assisted Reproduction

Can be used in a variety of ways besides helping infertile couples
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Couples who want to avoid genetic anomalies Sperm or egg donors Surrogate parent (mother, father, or both) Homosexual couples Single parents

Cloning of a lost child may someday be possible What to do with frozen embryos

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Assisted Reproductive Techniques (ART)

Examples include
  

In vitro fertilization (IVF) Gamete intrafallopian transfer (GIFT) In vitro fertilization−embryo transfer (IVF-EF)

Each begins with ovulation induction to permit retrieval of ova Maternal risks include multifetal pregnancy, preterm labor, preeclampsia, cesarean birth, ectopic pregnancy, pelvic organ damage or infection Fetal risks include prematurity, chromosomal anomalies

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Ovulation Induction

Woman is given medications to induce ovulation

Ovarian hyperstimulation syndrome is not uncommon when ovarian enlargement and follicular cysts are present

One of 3 medications

Selective estrogen receptor modulators  Aromatase inhibitors  Injectable gonadotropins

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Therapeutic Insemination
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Formerly known as artificial insemination Instillation of ova or sperm into uterus to aid conception Intrauterine insemination can also be used Donor sperm and ova may be frozen and held for 6 months before use to reduce risk of infections that may not have been detectable at initial screening

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Role of the Nurse in Contraception and Infertility

Assess contraceptive knowledge, attitudes and plans for pregnancy, need for family planning, and preferred methods Nurse is an educator, advocate, and counselor who offers the couple a sense of control and acceptance

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Question for Review

Why should birth control pills be delayed at least 4 weeks before restarting them after delivery?

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Review Key Concepts of the Chapter

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